general registration & medical release form

Please note our forms are for adult and minor campers. Please fill out all required sessions as applicable for you.

* Indicates required field

Name *

First

Last

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Summer Camp Session Selection *

Address *

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City

State

Zip Code

Country

Retreat Session Selection *

Camper's Email *

Camper's Phone Number *

Gender *

Adult/Minor *

Birth Date *

Grade In The Fall *

Pick-up authorization *

Please list the names of no more than four people or couples who are authorized to pick-up your child from camp. *Please send special written permission if camper is to leave camp during a session for practices, games, concerts, etc.

Roommate Request *

please list one person you would like to room with.

Over The Counter Medication *ie tylenol, Benadryle... *

Allergies? If yes please list in the box to the right. *

YesNo

Are You Allergic To Any Medications? If yes please list in the box to the right. *

YesNo

Are You Currently On Any Medications? If yes Please list in the box to the right. *

YesNo

List Serious Allergies *

List Medication Allergies *

List of Medications *

Have You had a seizure in the last 12 months If yes please list in the box to the right. *

YesNo

Do you have heart defects, disease or high blood pressure? If yes please list in the box on the right. *

YesNo

Do you have debilitative back, knee or similar structural disorders? If yes please list in the box on the right. *

YesNo

If yes please list the medication for this seizure condition *

Heart issue *

Structural Disorder *

Have you had any serious sprains, broken limbs or surgery of any kind in the last 12 months? If yes please list in the box on the right *

YesNo

Are you or do you believe yourself to be pregnant? *

YesNo

Please list spraines, sugeries... *

Year of last tetanus shot *

Insurance Provider Name *

Policy # *

Physicians Name *

Physicians Phone Number *

AUTHORIZATION FOR tREATMENT/ eMERGENCY cARE

I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests and treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp executive director to secure and administer treatment, including hospitalization for the person named above. This complete form may be photo copied for trips out of camp. The health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities as noted. I agree to release and hold harmless Koinonia Camp, its employees and volunteers from any and all claims including, but not limited to physical or property damage suffered by my child as a result of attending a camp or travel during camp. During travel, I understand that my child will be accompanied by a responsible adult and every precaution will be taken to safeguard the welfare of the campers.

Father's Name *

Mother's Name *

Family Email *

Father's Phone Number *

Mother's Phone Number *

Emergency Contact Name *

Emergency Contact Phone # *

Church's Name *

Church Phone # *

Physical Activity Release

​ Camp Activities include, but are not limited to hiking, swimming, low and high Koinonia Adventure course activities, canoeing, horseback riding, archery and paintball adventure games. There are risks of physical injury or harm from participating in high adventure activities. I voluntarily elect to participate in the activities and assume the risks of injury of harm that could result from participation. On my own behalf and that of my personal representatives and heirs, I hereby release Koinonia Camp its officers, employees, and agents from all liability for any injury or harm to me (or my minor) from participating in said activities; whether the injury or harm is caused by the negligence of Koinonia Camp or otherwise. I have read and understood this release of liability. Participation in the physical aspects of any or all outdoor initiatives is absolutely voluntary. I acknowledge the fact that not all of the stresses and hazards connected with the activities can be foreseen. Some of the specific hazards I might encounter include slipping and falling on trails, bumps, bruises, cuts, scrapes, insect stings, poison ivy, sprains or other injuries. Facilitators will take every reasonable precaution to minimize exposure to known risks. I have the personal responsibility to follow all the safety rules and guidelines given to me. I hereby personally assume all risks in connection with the activities and I waive all claims arising out of the safety rules and guidelines given to me.

Activity Release *

Low InitiativesHigh RopesSmall Animal ExperiencesPaintball

*Please note that by registering your child for this camp you are giving Koinonia Camp permission to take and use pictures and videos for promotional purposes.*

If you would like to pay the full overnight camp/retreat or One day event session fee online please visit our Camp Store Page​by clicking the store icon on the left​and choose the session you plan to attend.

One Day Event Form

* Indicates required field

Select One *

# of guests *

Name *

First

Last

Email *

Mailing Address *

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City

State

Zip Code

Country

Phone Number *

Emergency Contact's Name *

Emergency Contact's Phone # *

After you submit this form​if you wish to pay online please click the store icon above or go to our camp store page and follow the links to your chosen retreat or event.

Equine release form

* Indicates required field

Date *

Name *

First

Last

Email *

Phone Number *

By and between Koinonia Camp & Conference Center, hereinafter referred to as MANAGER and the participant filling out this form hereinafter referred to as PARTICIPANT. For consideration received, and in return for the use today, and on all future dates of the property, facility and services of Manager, participants, participant’s heirs, assigns and representatives of, hereby agree as follow:Inherent risk and Assumption of Risk. The undersigned acknowledges there are Inherent risks associated with equine activities. The inherent risks include but are not limited to, the propensity of equines to behave in ways such as running, bucking, kicking, biting, shying, rearing, falling or stepping on, that may result in injury, harm, or death to persons on or around them; the unpredictability of the equines reactions to things such as sounds, sudden movements and unfamiliar objects, persons or other animals; certain hazards such as surface and subsurface conditions; collisions with other animals; the limited availability of emergency medical assistance; and the potential of a participant to act in a negligent way that may contribute to injury to the participant or others, such as failing to maintain control over the animal, not acting within the participant’s ability, or not followin instructions. Participant acknowledges that horses, by their very nature are unpredictable and subject to animal whims. Participant assumes all responsibility in connection there in, and expressly waives any claims for any injury of loss arising therefrom. Participant agrees to abide by and follow Manager’s rules and regulations which shall be stated, posted and/or available from time to time. Participant further acknowledges that the behavior of any animal is contingent to some extent upon the ability of the participant. Participant assumes all risks therefore and warrants a full and fair disclosure of the participant’s abilities has been made to manager.

I have ridden: *

NeverBeing LeadMore than onceOften

check all that apply to you

Gaits I have ridden *

WalkTrottCanterGallop

check all that apply for you

Participant expressly releases manager from any and all claims for personal injury or property damage, even if caused by negligence on the part of the manager (if allowed by the laws of the state of Ohio) by manager, representatives or employees. Warning Under Ohio law, an equine activity sponsor, equine activity participants, equine professional, veterinarian, farrier, or other person is not liable in damages in a tort or other civil action for harm that an equine activity participant allegedly sustains during an equine activity and that results from inherent risks associated with the activity pursuant to Ohio revised code annotated 2305.321 (2001)

Release of Liability Participant agrees to hold harmless, indemnify, and defend manager against, and hold harmless from, and all claims, demands, causes of action, damages, orders, judgments, costs or expenses, including attorney’s fees., whether actually incurred or not, which may in any way arise from or in any way be connected to the participants use of or presence upon the property of the manager or the facilities thereof.

In the event that the participant is using participants own horse(s), or a horse(s) not owned by manager, participant warrants said horse shall be free of infection, contagions or transmittable diseases. Manager reserves the right to refuse access of use of any horse upon the premises that does not appear to manager to be in good health, or is dangerous or in any way deemed undesirable by manager.

Any action brought under this agreement shall be brought within (1) year of the incident of accident giving rise to said claim. Participant agrees damages shall be limited to $250 in property damage, actual expenses incurred, and a maximum of $10,000 for damages such as pain and suffering.

Participant agrees to waive any applicable statutes in this jurisdiction whose purpose, substance and/or effect, is to provide that a general release shall not extend to claims, material or otherwise, which the person giving the release does not know or suspect to exist at the time of executing said release.

rOUGH rIDERS vOLUNTEER Application

Koinonia Campis working with Shriners Childrens Hospital in Erie P.A. to reach out and help kids using our horses! We must insure that we have enough staff to help each child reach their goals. If you are willing to give an hour or two each week to this life changing opportunity please fill out the form below and we will contact you.

* Indicates required field

Name *

First

Last

Address *

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City

State

Zip Code

Country

Email *

Phone Number *

Please check the box next toall datesthat you are interested in volunteering during the next eight week block. Please note that if you just want to lead a horse or be an off side walker you do not need to be present every session. If you want to be a Rough Rider Partner(work directly with kids) you must commit to all sessions during the eight week block(16 sessions total - all Mondays and Thursdays)

background Information

Have you ever been arrested. plead no contest, and/or been convicted of any crime? *

Yesno

Has anyone ever taken or threatened to take adverse employment action against you for reasons relating to allegations of physical or sexual abuse or sexual harassment. *

YesNo

Has an employer ever taken or threatened to take adverse employment action against you for reasons relating to allegations of physical or sexual abuse or sexual harassment. *

YesNo

Have you ever been accused of , participated in , or been convicted of child sexual abuse? *

YesNo

Have you ever been charged, accused or convicted of any crime related to the abuse, mistreatment, or molestation of children or youth? *

YesNo

If selected to be a camp counselor, I agree to abide by the Bylows and policies of the American Baptist Churches of Akron, Ashtabula, and Cleveland and the Camping Ministry at Koinonia. I also give Koinonia Camp permission to take and use pictures and videos for promotional purposes.

RELEASE

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they may have reguarding my character and fitness for service with children, youth or vulnerable populations.

I voluntarily release the organization and any such person or entity listed herin from liability involving the communication of information relating to my background or qualifications. I further authorize the organization to conduct a criminal background investigation if such a check is deemed necessary.I have read and understand the contents of this application and the Volunteer Staff Handbook and sign it of my own free will.

Applicant's Signature *

Date *

Witness' Signature *

Date *

References

Please list three persons (besides the pastor or your family members) who could speak to your qualifications and abilities to be a camp counselor:

Name *

First

Last

Phone Number *

Address *

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State

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Name *

First

Last

Email *

Name *

First

Last

Phone Number *

Address *

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Email *

Name *

First

Last

Phone Number *

Address *

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Email *

Please enter any additional information you would like to share with us in the space below.